Corporate Profits and the DSMs: The Case of the Tobacco Industry

In the run-up to publication of DSM-5, there was much discussion of the extent to which the pharmaceutical industry—“Big Pharma”—stood to profit from the revisions. There were accusations that members of the DSM-5 Task Force and the specialist committees (Work Groups) had conflicts of interest because they could benefit financially from ties to drug manufacturers. The American Psychiatric Association (APA) did more than one round of vetting to pare down members’ industry connections, and the external critical attention being paid to this issue largely subsided. Such thorough scrutiny by the APA of possible financial conflicts of interest was a new phenomenon. With previous DSM Task Forces and Advisory Committees, these kinds of insistent demands had not been made.

It was obvious that questions would arise about the pharmaceutical industry’s possible influences on the development of diagnoses. However, there is no evidence that anyone suspected in the 1970s that the tobacco industry was attempting to suppress the development of the new diagnosis of “Tobacco Dependence” that ultimately appeared in DSM-III (1980.)

DSM-II (1968) had conspicuously included in the section on “304—Drug Dependence” the following statement: “This category is for patients who are addicted to or dependent on drugs other than alcohol, tobacco, and ordinary caffeine-containing beverages.”1(p45) However, Robert L. Spitzer, head of the DSM-III Task Force, had made the decision to make the new manual as useful as possible for clinicians and therefore to incorporate many diagnoses that had never before appeared in DSM, including one on tobacco use. Spitzer’s intention meant his taking on the scorn of millions and the reproach that he was “medicalizing normal behavior.” Half the nation smoked in 1970, but Spitzer was never fazed by confrontation. He proposed to create a diagnosis for smokers who were distressed at their inability to stop cigarette smoking or for those who had become visibly ill as a result of smoking but still did not stop.

No sooner had Spitzer announced his intent in 1975 to add a diagnosis of “Tobacco Use Disorder” in the new manual, than predictability he became the butt of various jibes. But matters became serious when he received a letter from the Director of the Division of Mental Health Services of the State of North Carolina, Nakhleh P. Zarzar.2 This letter was actually the first shot in a careful and low-key, behind-the-scenes campaign on the part of the tobacco industry to influence Spitzer, although there was no way he would have known that at the time.

Zarzar blusteringly warned Spitzer against his “unwise move” that would “complicate” state hospital reporting and might mean that “state hospital physicians will have to treat all those with such a diagnosis.”2 The DSM-III Task Force should not act “lightly.” To strengthen his hand, Zarzar included a letter from Richard C. Proctor, Chair of the Department of Psychiatry at Bowman Gray Medical School in Winston-Salem, North Carolina, also protesting the proposed new diagnosis. What Spitzer did not know was that Proctor was a paid tobacco industry consultant.

That information emerged in 2003 when researchers gained access to tobacco industry documents showing beyond doubt that industry executives had carefully monitored Spitzer’s work once he made public an initial draft of DSM-III in 1976.3,4 A confidential internal Philip Morris (PM) memo of that year describes the company’s surveillance of the activities of Spitzer and Jerome H. Jaffe, Spitzer’s expert adviser on tobacco use as a mental disorder.5 The information gathered was then sent to the chief lawyers of all the tobacco companies by Horace R. Kornegay, head of the industry’s Washington-based lobbying and political arm, the Tobacco Institute. Kornegay soon circulated the plan of action by the Institute: Proctor would write to “a substantial number of his colleagues” stating his objections to Spitzer’s plan.

Tobacco industry documents show that Proctor also wrote twice, quite politely, to Spitzer, interestingly using his (Proctor’s) home address and not psychiatry department stationary. A blind copy of Proctor’s first letter went to Colin Stokes, Chair of R.J. Reynolds Industries. The main thrust of Proctor’s position was that because overeating and consequent harmful obesity is not a psychiatric disorder, tobacco use should not be classified as one either. Spitzer, who answered every letter he received regarding DSM-III, responded that tobacco use is considered a mental disorder only when it causes distress to the individual, not when it posed a risk for disease. He cordially thanked Proctor for “sharpen[ing] our thinking in this very difficult area.”6

Proctor fulfilled his consultancy by sending successive drafts of DSM-III to Frank G. Colby, manager of the RJR Scientific Information Division.7 He was also quoted in an article in Psychology Today, titled “Who’s Mentally Ill?”, deriding making tobacco use a psychiatric diagnosis and adding: “I trust that, too, when the DSM-IV is compiled, missing a three-foot putt on the 18th hole will be classified as a psychiatric diagnosis.”8 A New York City psychiatrist, Leonard Cammer, wrote to Spitzer in a libertarian vein—with a copy to Proctor—arguing that “every distress in life is not a sickness and the person should be free to make certain choices even if unhappily, such choices make him ill.”9

The definition of tobacco dependence narrowed over the course of successive drafts of DSM-III, but it is impossible to know if the tobacco industry was responsible for these changes. All we definitively know is that they surreptitiously tried to influence Spitzer and even kept up their efforts after DSM-III was published, with an eye to future revisions of the manual. Proctor, without disclosing his tobacco industry connection, wrote to George Tarjan, president-elect of the APA, 9 months after DSM-III appeared, voicing his concern about possible insurance coverage “problems.” He also wrote in 1983 to Gary L. Tischler, then Chair of the Department of Psychiatry at Yale, warning about “political issues” that might arise with declaring the use of snuff and chewing tobacco as “indicat[ing] mental illness.” Tischler was involved in an APA conference in October of 1983 to evaluate DSM-III and eventually edited a book with the conference papers.10 (Proctor, ever vigilant, actually wrote to Tischler while the conference was still in the planning stages.)

The tobacco industry also supported broad-based efforts that did not deal directly with the issue of tobacco use. The industry-funded Council for Tobacco Research (CTR) awarded $637,000 over the course of a few years in the late 1970s and early 1980s to Alfred M. Freedman (editor of a renowned psychiatric textbook) and Richard Brotman. Freedman and Brotman asked for funds for an “analysis of policy in issues dealing with control and regulation of routine behavior in a democratic society.” The monies were variously distributed to create a Center for Behavioral Analysis of Policy Issues, support several conferences related to “critical issues in psychiatric classifications which have arisen as a result of DSM-III,” and to publish a monograph, Issues in Psychiatric Classification: Science, Practice and Social Policy.11 The book does not include any references to funding by tobacco companies or the CTR.

Ultimately, tobacco industry efforts to prevent the inclusion of a diagnosis for tobacco dependence in the DSMs failed. In DSM-III-R and DSM-IV, the relevant language changed to “nicotine dependence” and appears as “nicotine use disorder” (NUD) in DSM-5. Not only language has changed, however. In this new era of mandatory publication of all industry ties, all DSM-5 Task Force and Work Group members had to prepare comprehensive disclosure reports of their academic activities and commercial connections and to consent to a self-limiting ordinance with regard to income.

To take just one example, Charles P. O’Brien, Chair of the Substance-Related Disorders Work Group, which dealt with matters of tobacco use, published his academic connections and commercial ties since 2005.12 He agreed that “from the time of approval through the publication of DSM-5, projected in 2013, his aggregate annual income derived from industry sources (excluding unrestricted research grants) will not exceed $10,000 in any calendar year.” Dr O’Brien stated he was at present a consultant for Embera NeuroTherapeutics, Inc., a pharmaceutical company devoted to “smoking cessation, cocaine dependence, and other addictions” and for Alkermes, pursuing “innovative medicines designed to help patients with serious, chronic conditions better manage their disease.”

Fifty years stand between the start of the making of DSM-III and the publication of DSM-5. We are now confronting an era in which the commercial temptations for researchers have shifted. While we no longer have companies in the US that wish to maintain and expand the use of tobacco, knowing its harm, we now know it is possible that pharmaceutical companies may be promoting medications they know are of little value—which some physicians will endorse if they are paid enough. It seems likely that enticements for funding and consequent conflicts of interest will remain in medicine.